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Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY
Prerhinoplasty Facial Analysis
Article Last Updated: Jul 31, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Andrew A Winkler, MD, Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Director, Division of Facial Plastic and Reconstructive Surgery, University of Colorado Hospital
Andrew A Winkler is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American Academy of Otolaryngology-Head and Neck Surgery
Coauthor(s):
Stephen M Weber, MD, PhD, Fellow in Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Division of Plastic and Reconstructive Surgery, University of Michigan;
Brian W Downs, MD, Assistant Professor, Department of Otolaryngology, Section of Facial Plastic and Reconstructive Surgery, Oregon Health and Science University;
Russell WH Kridel, MD, FACS, Clinical Professor, Director, Fellowship Program Director, Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Texas Medical School at Houston; Assistant Clinical Professor, Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine;
Roger E Horioglu, MD, Consulting Staff, Department of Otolaryngology-Facial Plastic Surgery, South Shore Otolaryngology
Editors: Paul S Nassif, MD, FACS, Consulting Surgeon, Facial Plastic and Reconstructive Surgery, Spalding Drive Cosmetic Surgery and Dermatology; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
prerhinoplasty facial analysis, plastic surgery, cosmetic surgery, rhinoplasty, nose job, prerhinoplasty facial analysis, facial aesthetics, facial asymmetry, nasal deformity, facial beauty, facial analysis
An enormous demand for plastic and reconstructive surgery exists in the United States. In 2002, over 3.5 million operative cosmetic and reconstructive procedures were performed.1 Rhinoplasty is the most commonly performed cosmetic operation reported by facial plastic and reconstructive surgeons.2 As the most anterior projecting facial feature, the fact that a large number of people seek surgical alteration of the nose is not surprising. Even small abnormalities of this central facial element can lead to major disharmonies in global facial aesthetics.3
Rhinoplasty is among the most challenging of all plastic surgical operations. Countless techniques have been developed to creatively alter the size, shape, and function of the nose. The experienced rhinoplastic surgeon uses a thorough knowledge of nasal anatomy and normal facial aesthetics to choose the techniques best suited to each particular nose. Careful preoperative nasal and facial analysis is imperative to ensure a satisfactory result in rhinoplasty. Accurately identifying the correct structural determinants of the nasal aesthetic form is the key to choosing the correct rhinoplasty techniques. In this article, the issues surrounding nasal and facial analysis are discussed as they pertain to planning for aesthetic and functional rhinoplasty.
Man has long tried to capture the beauty of the human face. Praxiteles’ Aphrodite from 450 BC was considered a standard for artistic beauty for several hundred years (see Image 1). The Renaissance artists of the late 14th century furthered the ancient Greek canons of beauty and described a set of proportions known as the neoclassical canons of beauty. Our ideals of beauty have changed over the last several hundred years, but these concepts are built on the foundations of past artists and scholars, as well as innate aesthetic preferences. With the advent of modern media, our popular icons have shaped or have been shaped by our concept of beauty.
The concepts of facial disharmony and disproportion are vital to a discussion of beauty. Disproportionate features are those which lie outside 2 standard deviations from the mean. However, disproportionate facial features can be harmonious with one another if the global appearance is aesthetically pleasing. In a comparison of 29 separate female nasal measurements, Farkas et al found that 70% of the women judged to be attractive had nasal measurements that were within 1 standard deviation from the mean.4 The author argues that proportionate nasal features are more easily harmonious with facial features that may be disproportionate.
Interestingly, homogenous opinions concerning beauty exist across cultures. Cross-cultural consistency results from an evolutionary process linking physically attractive features to biological or social fitness. In humans, estrogen-dependent characteristics of the female body correlate with health and reproductive fitness and are attractive based on several studies.5, 6 To evaluate the strength of innate human preferences of facial attractiveness, Perrett et al digitally enhanced female human faces.7 The altered photographs exaggerated the sex-hormone-related cues of youth and fertility in the female face. The authors found that subjects from different cultures preferred the digitally feminized faces to the average female face. Although this preference was stronger within the culture, it was also consistent across cultures.
Prerhinoplasty evaluation is not complete without a thorough history, which begins with a discussion about the patient's motivations. The surgeon must elucidate exactly what bothers the patient about their nose and decide if this is amenable to surgical change. Properly motivated patients have a healthy self-esteem and seek restorative changes to the nose. Having realistic expectations of postoperative results as well as the postoperative recovery period is vitally important for the patient
Patients seeking cosmetic changes to the nose are generally psychiatrically stable, but a brief psychiatric assessment is wise. Body dysmorphic disorder is a psychiatric condition involving preoccupation with an imagined or slight defect in appearance that leads to markedly excessive concern. This preoccupation causes significant distress or impairment in social, occupational, or other areas of functioning.8 In general, cosmetic surgery patients are no more dissatisfied, critical, or preoccupied with their overall appearance than a nationwide sample of Americans.9 However, patients seeking dramatic changes to the nose should be approached with caution, and a psychiatric consult may be warranted.10
The 6 standard preoperative rhinoplasty views are the frontal, right, and left oblique; right and left lateral; and the basal views. The frontal, oblique, and lateral views should be taken with the patient in the Frankfort horizontal plane. This plane is achieved when the head is positioned such that an imaginary line drawn from the superior aspect of the external ear canal (the porion) to the inferior orbital rim lies parallel with the horizon (see Image 2). Lighting should provide for a somewhat harsh view of the nose and should not wash out fine details or shadows.11 Frontal view A properly oriented frontal view has the patient in the Frankfort horizontal position with both pinnae showing symmetrically. The face may be divided into sagittal fifths and horizontal thirds (Image 3). The width of each sagittal fifth of the face approximates the width of each eye. The width of the nasal base should approximate but not exceed the central fifth, or the intercanthal distance.
Dividing the facial height from the central hairline to the bottom of the chin into thirds is also useful. The superior border of the upper eyelid forms the division between the upper and middle thirds. The subnasale (junction of the columella with the upper lip) forms the division between the middle and lower thirds. The nose should occupy the middle facial third.
The nose can also be described in terms of transverse thirds. This division is visually convenient and also has an anatomic correlation. The nasal bones form the upper third, the upper lateral cartilages and septum form the middle third, and the lower lateral cartilages form the lower third (see Image 4). - Bony third: The nasal bones should be symmetric, and the width should be approximately 75% of the intercanthal distance. Asymmetries in the bony third should be noted and may be treated with medial, lateral, or intermediate osteotomies.
- Middle cartilaginous third (midvault): Lines connecting the clubhead of the eyebrow to the ipsilateral tip-defining point are known as the brow-tip aesthetic lines.12 These lines should be curvilinear, symmetric, and should demonstrate a smooth transition at the midvault. Deformities from trauma or prior surgery (eg, an inverted-V deformity) disrupt the brow-tip aesthetic line. A narrow middle third suggests the possibility of nasal valve dysfunction.
- Nasal tip
- The symmetry and size of the nasal tip should be noted. A slight supratip break should be at the junction of the middle third with the nasal tip. The tip shape is characterized, according to standard terms, as bulbous, narrow, bifid, boxy, or amorphous. The concept of an aesthetic diamond is a useful concept when visualizing the tip and was first described by Sheen.12
- The elegant tip forms a diamond shape composed of the 2 tip-defining points, the supratip break (vertically), and the infratip lobule break (in the midline). The domes of the medial crura should diverge from each other at 50-60º. Narrow divergence causes the tip-defining points to be too close together and gives a pinched appearance. The position and fullness of the lateral crura of the lower lateral cartilages is noted. Finally, the nasal rims should form a "gull-in-flight" relationship with the columella.
Lateral (profile) view The dominant characteristics of the nasal profile are the projection and rotation of the nasal tip, the nasal length, and the dorsal nasal contour. Nasal projection refers to the distance from the anterior facial plane to the tip-defining point. The anterior facial plane is defined by an imaginary vertical line connecting the nasion with the point where the alar groove intersects with the superior aspect of the melolabial fold. Projection is assessed in relation to the overall nasal length, which is the distance from the sellion (defined below) to the tip-defining point.
The normal projection–to–length ratio is 0.55-0.60. Alternatively, the distance from the base of the columella (the subnasale) to the nasal tip should equal the length of the upper lip, if the lip height is normal. Although some surgeons make extensive measurements on preoperative photos, as a practical matter making such calculations at the initial patient encounter is difficult.
Integral to altering nasal length is an understanding of the soft-tissue starting point of the nasal dorsum, termed the sellion (as opposed to the nasion, which is the bony starting point of the dorsum). The sellion represents the soft-tissue vertex of the nasofrontal angle, which is the angle formed between the dorsum of the nose and the beginning of the forehead/glabella. The ideal nasofrontal angle is approximately 120º (Image 5).
Several authors have offered their opinions about the ideal position of the sellion and consequently the starting point of the nose. Sheen suggested that the sellion be placed at the supra tarsal fold, based on his personal observations over many years of clinical practice.12 However, the position of the supratarsal fold in Caucasians is variable and may be absent in Asian individuals.
In 2004, Mowlavi, et al asked a group of volunteers to evaluate black and white drawings of a female profile that were identical except for the position of the sellion.13 They discovered that the most preferred position differed between men and women judges, and that many different positions were chosen as attractive. However, the most commonly cited position of the sellion by rhinoplastic surgeons is the supratarsal crease. The position of the sellion on lateral view can help to determine whether augmentation of a deficient radix or resection of a dorsal hump is needed.
A straight, high dorsal profile is the currently accepted standard. A slightly scooped appearance of the dorsum in females or a slight dorsal hump in males may be acceptable.
Nasal tip rotation occurs along an arc from the tip-defining point around the porion. An indirect measure of tip rotation is the nasolabial angle, which is the angle formed between the columella and the upper lip. Angles of 90-105° for men and 95-110° for women are considered to be the aesthetic ideal. However, these angles are approximations and narrower angles are appropriate in taller patients. In a female of average height, the shadows inside of the nose should be barely observed above the nasal sill when the facial plane is perpendicular to the Frankfort plane. If the entire sill cannot be viewed, the nose can tolerate rotation. Specific patient or surgeon preferences may modify these guidelines.
The well-defined nasal tip will have a "double-break" with the first break 1-3 mm above the tip-defining point and the second break is at the junction of the infratip lobule and the columella. The nasal tip should lead the nasal dorsum by 1-2 mm, creating a slight supratip break (see Image 6). Some surgeons routinely perform a smiling lateral view to document the plunging tip deformity, a condition wherein the tip of the nose plunges with smiling due to contraction of the depressor septi nasi and the levator labii superioris alaeque nasi.
The relationship of the alar rims to the columella should be carefully assessed. The alar rim should arch 2-3 mm above the columella on this view. Deviations indicate alar or columellar retraction that may need to be addressed.
A critical component to the profile assessment is the relative prominence of the chin. In women, the chin should project to a point 3-4 mm posterior to the coronal plane through the vermilion-cutaneous junction of the lower lip. In men, the chin should project to or near this point (see Image 7). If much less chin projection is observed, microgenia is present and the patient is offered chin augmentation. In these patients, avoiding the sense of an overprojecting nose without chin augmentation is difficult, even after appropriate reductive rhinoplasty. Showing these patients appropriate images to illustrate the key relationships is often helpful.
Oblique view
The right and left oblique photographs are appropriately oriented when the tip of the nose lies tangential to the contralateral malar eminence. These views are ideal for demonstrating the ipsilateral brow tip aesthetic lines. Further assessments can therefore be made regarding the asymmetries or prominences of the nasal dorsum.
Basal view To assess the nasal base, the patient's head is tilted back until the nasal tip projects on the midline point between the eyebrows along the axis of the surgeon's view (see Image 8). The base is ideally an equilateral triangle. This triangle can again be divided into thirds, with the nostrils extending two thirds of the length from the nasal-facial junction to the nasal tip. The remaining third comprises the infratip lobule. The nostrils should have symmetric opposing kidney shapes, with indentations created by the flare of the medial crural footplates of the lower lateral cartilages. Asymmetry of the nostrils demands a search for an explanation. Possible causes include alar scar retraction, prior nasal surgery, dislocation of the caudal septum off the maxillary spine, and congenital nostril asymmetry. The width of the alar base is best assessed on the basal view. The ideal width is precisely the intercanthal distance. The base view superimposes the lateral alar margins on the medial canthi, which makes this assessment easy. Note that decreasing tip projection intraoperatively increases alar flare and the width of the alar base, which may necessitate alar base reduction.
The contours and symmetry of the nasal tip should again be assessed on this view. The elegant tip has a smooth curvilinear transition from the medial crura to the intermediate crura and tip-defining points. A bulbous tip is convex anteriorly and laterally and often leads to a trapezoidal shape of the nasal base. Bifidity of the nasal tip may be observed in widely divergent domal segments. The base view is useful for confirming impressions of tip projection and symmetry. In assessing projection, the base is visualized with the alar width set at the ideal intercanthal distance. If the triangle formed by the patient's tip position is more elongated along the AP axis than an equilateral triangle, the tip is probably overprojected; if shorter, the tip is probably underprojected. Asymmetries are readily identified as a tilting of the nasal base triangle (see Image 9).
Of the 6 standard views, skin/soft-tissue envelope thickness can be estimated best from the basal view, although it should always be confirmed by palpation. The lower lateral cartilages of some individuals can be visualized through nearly transparent skin. Thicker-skinned individuals demonstrate more sebaceous gland hypertrophy of the infratip lobule.
External exam
- Observation: The rhinoplastic examination begins with an observation of the patient during quite respiration. Note whether the patient is breathing through the mouth or nose. When breathing quietly through the nose, document collapse of the lateral nasal sidewalls if present. The sebaceous gland concentration in the nasal skin is also confirmed, as are any other asymmetries or abnormalities. The internal and external nasal valves should then be observed during sniffing. The external valve is formed by the columella medially and the alar sidewalls laterally. External valve collapse is often noted in thin-skinned individuals with narrow nostrils. The internal nasal valve is a more common cause of nasal airway obstruction and is discussed below.
- Palpation
- Some understanding can be gained by observing the nose in detail, but no substitute exists for palpating the nose. All external areas of the nose must be palpated because a wealth of important information is obtained in this way. Bony and cartilaginous irregularities are identified. The thickness of the skin is verified. Gentle ballottement of nasal tip gives information regarding its structural integrity and support. Knowledge of these characteristics is absolutely essential for developing a surgical plan and is obtained by combining vision with directed palpation.
- The thickness of the skin/soft-tissue envelope contributes significantly to postoperative results. The final visual result in nasal contour is an interaction between the outer soft tissue envelope and the underlying bony and cartilaginous skeleton. Thick skin does not contract well and, therefore, is poorly suited to aggressive reduction. Meticulous shaping of the nasal skeleton may be hidden under thick skin and may result in loss of elegant tip detail. Conversely, thin skin, although able to show the details of the underlying skeleton, also shows minor imperfections in tip symmetry and contour. Most patients lie on the continuum between these 2 endpoints.
- Ballottement of the nasal tip gives information regarding tip support to the experienced rhinoplastic surgeon. The major tip support mechanisms include the size, strength, and resiliency of the lower lateral cartilages, the articulation of the upper with the lower lateral cartilages at the scroll region, and the connection of the medial crural footplates with the caudal septum.14 These support mechanisms take on different degrees of importance in each patient. However, ballottement of the nasal tip provides knowledge of the summated effect of the various major and minor support mechanisms. This knowledge can in turn be used to guide decisions about surgical maneuvers that will reduce support and whether it will need to be augmented.
- Palpation of the anterior septum should also be performed. Bidigital manipulation of the caudal septum and its relationship to the medial crura can be obtained by gently grasping and rotating the columella. Deviations of the caudal septum are commonly diagnosed and cause deflection of the nasal tip. If the anterior septal angle can be palpated above the nasal tip and projects above the dorsal contour, then the tension-tip nasal deformity is present. In this case, the anterior septal angle plays a major role in tip support and must be accounted for in the surgical plan.
Internal examination - Nondecongested examination
- The surgeon who improves the aesthetics of the nose while creating or tolerating airway compromise or sinus dysfunction does the patient no service. Therefore, performing a speculum examination of the nasal cavity and assessing the nasal airway is important. The internal nasal valve is formed by the caudal edge of the upper lateral cartilage, septum, and the floor of the nose. This area is the single greatest contributor to airway resistance and is examined in every rhinoplastic patient.
- Often, the inferior turbinate is hypertrophied or is otherwise contributing to nasal congestion, which should be noted. Septal deflection, fractures, spurs, and other abnormalities are essential to surgical planning for functional rhinoplasty and should be documented. One should also rule out benign or malignant neoplasia as the cause of nasal airway obstruction. If any concern exists or if an identifiable cause of nasal airway obstruction is not found anteriorly, a flexible fiberoptic examination of the nasopharynx should be performed.
- Assessing for the presence or absence of septal cartilage is also wise. This is especially important in cases of revision rhinoplasty in which septal cartilage may have been previously harvested. A paucity of septal cartilage may prompt the surgeon to harvest cartilage from other sources (eg, ear, rib).
- Specific tests
- Nasal tip ptosis is a common cause of airway obstruction, especially in the older patient. Superior rotation of the tip with a finger while the patient inspires is a helpful maneuver that aids in the diagnosis of this problem, as well as illustrates the surgical treatment.
- The Cottle maneuver is performed in all patients with nasal airflow obstruction. This is performed by pulling the midfacial soft tissue laterally at the melolabial folds. Improvement in nasal airflow with this maneuver is diagnostic for internal nasal valve collapse. A modified Cottle maneuver is performed using a cerumen loop to manually lateralize the upper lateral cartilages. Improvement in nasal airflow during this maneuver is helpful in predicting the success of nasal valve surgery.
- Decongested examination: To decongest the nose, topical phenylephrine is applied using an atomizer. The inferior turbinate is examined and compared with the nondecongested state. This helps to determine the presence of turbinate hypertrophy that may need to be addressed. With the nasal mucosa decongested, more of the posterior septum and nasal cavity is revealed. Any new septal deflections, septal spurs, or deviations of the perpendicular plate of the ethmoid are noted. The internal and external nasal valves are again examined in the manner outlined above.
Preoperative analysis of the rhinoplasty patient is exceedingly complex but comparably rewarding. Specific directed techniques must be chosen and executed expertly, with the knowledge that each maneuver usually alters several characteristics of the nose at the same time. An appropriate marriage of analysis and technique yields the greatest opportunity for achieving the most important goal of any cosmetic surgery: a satisfied patient.
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Praxiteles' "Aphrodite" from 450 BC was considered a standard for artistic beauty for several hundred years. Unfortunately, it was destroyed in a fire in 475 AD. This replica of his statue was found in Rome and dates to 150 BC. |
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Lateral view demonstrating the Frankfort horizontal plane. |
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Anteroposterior view divided into sagittal fifths and transverse thirds. |
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Nasal height divided into transverse thirds, with the upper third corresponding to the nasal bones, the middle third to the upper lateral cartilages, and the lower third to the lower lateral cartilages. |
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An aesthetically pleasing slight supratip break (arrow). |
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Lateral views demonstrating male and female chin projection, measured with respect to the vermillion-cutaneous junction. |
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Basal view of the nose should approximate an equilateral triangle as shown, with the nostrils extending to two thirds of the distance from the base to the nasal tip and the infratip lobule making up the remaining third. |
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- Krieger LM, Lee GK. The economics of plastic surgery practices: trends in income, procedure mix, and volume. Plast Reconstr Surg. Jul 2004;114(1):192-9. [Medline].
- Alsarraf R, Larrabee WF Jr, Johnson CM Jr. Cost outcomes of facial plastic surgery: regional and temporal trends. Arch Facial Plast Surg. Jan-Mar 2001;3(1):44-7. [Medline].
- Powell, N. and Humphreys, B. Proportions of the Aesthetic Face. New York, N.Y.: Thieme-Stratton; 1984.
- Farkas LG. Linear Proportions in Above- and Below-Average Women's Faces. In: Anthropometric Facial Proportions in Medicine. Springfield: Thomas; 1987:119-29.
- Singh D. Ideal female body shape: role of body weight and waist-to-hip ratio. Int J Eat Disord. Nov 1994;16(3):283-8. [Medline].
- Barber N. Secular changes in standards of bodily attractiveness in women: tests of a reproductive model. Int J Eat Disord. May 1998;23(4):449-53. [Medline].
- Perrett DI, Lee KJ, Penton-Voak I, et al. Effects of sexual dimorphism on facial attractiveness. Nature. Aug 27 1998;394(6696):884-7. [Medline].
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. IV. Washington D.C.: 1994.
- Sarwer DB, Wadden TA, Pertschuk MJ, et al. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. May 1998;101(6):1644-9. [Medline].
- Goin JM, Goin MK. Changing The Body. In: Psychological Effects Of Plastic Surgery. Baltimore, Md: Williams & Wilkins; 1981.
- Galdino GM, DaSilva And D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg. Apr 1 2002;109(4):1421-34. [Medline].
- Sheen JH, Sheen AP. Klein EA. Aesthetic Rhinoplasty. 2nd. St. Louis: The C.V. Mosby Company; 1987.
- Mowlavi A, Meldrum DG, Wilhelmi BJ. Implications for nasal recontouring: nasion position preferences as determined by a survey of white North Americans. Aesthetic Plast Surg. Nov-Dec 2003;27(6):438-45. [Medline].
- Tardy ME Jr, Brown RJ. Surgical Anatomy Of The Nose. New York, NY: Raven Press; 1990.
Prerhinoplasty Facial Analysis excerpt Article Last Updated: Jul 31, 2008
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